Podcast Summary

Podcast: New Books Network
Host: Shu (SH1)
Guest: Dr. David Kieran
Episode: Signature Wounds: The Untold Story of the Military's Mental Health Crisis
Published: November 14, 2025
Book: Signature Wounds: The Untold Story of the Military's Mental Health Crisis (NYU Press, 2019)

Episode Overview

This episode delves into Dr. David Kieran’s acclaimed book Signature Wounds, which investigates the U.S. military’s evolving understanding and response to mental health crises among service members during and after the wars in Iraq and Afghanistan. Through a historian’s lens, Dr. Kieran explores institutional challenges, cultural stigmas, and the intersecting impacts of trauma, both for service members and their families.

Key Discussion Points & Insights

1. Origins and Motivation for the Book

• Interest Sparked by Veterans' Memoirs:
  Dr. Kieran was inspired to write after noticing the disconnect between how Iraq veterans described their mental health compared to Vietnam veterans, and the public narrative about veterans' psychological struggles.
  • "A lot of [Iraq veterans] were saying, well, we're not like Vietnam veterans. Vietnam veterans, they have PTSD. And I don't have PTSD. I'm fine." (Dr. Kieran, 02:14)
• Shift from Cultural History to Institutional Analysis:
  Initially planning to study public perception and cultural depictions, he pivoted toward examining the Army’s internal efforts and institutional challenges.
  • "...I realized that there was really a much more complicated story of what the army was doing to try to understand, diagnose, and treat mental health issues in the midst of two wars happening simultaneously..." (Dr. Kieran, 04:22)

2. Military Mental Health Doctrine Pre-9/11

• Legacy of Battle Fatigue Doctrine:
  The Army’s approach prior to the 21st century was rooted in treating acute combat stress, not long-term PTSD, with a focus on short, intense wars (i.e., a Cold War with the Soviet Union).
  • "...the army was really planning for...battle fatigue or combat fatigue...where a soldier would have an intense, acute reaction to the violence of war, and that they could treat that person with rest, with a change of clothes, with a hot shower." (Dr. Kieran, 06:24)
• Separation from Veteran Affairs:
  PTSD was seen predominantly as a veterans’ (post-service) issue, not active duty.
  • "The prevailing view inside the army was that that was really something that the VA did, that that was an issue for veterans, not for active duty soldiers." (Dr. Kieran, 07:00)

3. Development of the Mental Health Advisory Teams (MHATs)

• Origins in 1990s Peacekeeping Deployments:
  Techniques for surveying mental health stressors were adapted from corporate America and refined during peacekeeping operations.
  • "These were actually related to surveys that were going on in corporate America...and the army picked that up and adapted it..." (Dr. Kieran, 10:23)
• Rapid Deployment to Iraq:
  The Army used these teams to track mental health issues in real time in Iraq, starting as early as 2003, spurred by suicide clusters among deployed soldiers.
  • "They sent a team led by an army officer named Carl Castro...they already had the methodology created to do that kind of research from what they'd done in the 90s..." (Dr. Kieran, 10:48)
• Direct Influence on Policy:
  These real-time data collection efforts informed senior Army leadership on emerging issues, enabling targeted interventions.

4. Mental Health, Politics, and the Anti-War Movement

• Tensions Between Supporting Troops and Opposing the War:
  Mental health crises became a focal, less politically charged argument for anti-war advocates.
  • "Talking about mental health created an opportunity for people opposed to the war to say, look at the suffering and harm that is being delivered on these soldiers..." (Dr. Kieran, 13:46)
• Notable Quote:
  • "...if you love the troops and support the troops, you don't send them back to Iraq with a rifle and a bottle of antidepressants." — Paraphrasing Sen. Barbara Boxer, 15:01

5. Tackling Stigma and Making Care Accessible

• Culture of Toughness as Barrier:
  Soldiers were often reluctant to seek care due to military ideals of resilience and masculinity.
  • "It's hard enough to get these guys to come in when they have a broken bone. For them to come in with something they can't see is even more difficult." — Former Chief of Staff George Casey (16:45)
• 'Battlemind' and Normalizing Reactions:
  • "...the things that you learn how to do that help you actually survive and do well in a combat environment...might not be particularly good adaptations to a civilian environment." (Dr. Kieran, 17:45)
• Integrating Mental Health Into Primary Care:
  Routine physicals became opportunities to discuss emotional well-being, lowering the threshold for seeking help.
  • "Chuck's big idea was, how can we build mental health assessment and treatment into primary care, because that's where the people show up." (Dr. Kieran, 20:02)
• Embedding Care Providers in Units:
  By moving mental health professionals into soldiers’ daily environments, informal access increased, breaking down visible and cultural barriers.

6. Efforts (and Shortcomings) in Addressing Family Mental Health

• Strains on Families:
  The all-volunteer force meant most deployed soldiers had spouses and children enduring stress at home.
  • "I remember driving home every day...and hoping there wasn't a government sedan with a couple of officers and a chaplain waiting to tell me my husband had been killed." (Dr. Kieran, 24:21)
• Resource Gaps and Structural Barriers:
  There were never enough care providers, and families cannot be compelled into treatment as soldiers can.
  • "They didn't have enough providers at all even to meet the needs of the uniformed people. And then to add to that...ensuring that spouses, children got the care they need..." (Dr. Kieran, 23:37)

7. The Emergence of Traumatic Brain Injury (TBI) as a Signature Wound

• IEDs and New Types of Injuries:
  The advent of roadside bombs dramatically raised incidence and awareness around TBI.
  • "What became the major issue in the wars in Iraq and Afghanistan was the question of how traumatic brain injury...increased because of...improvised explosive devices..." (Dr. Kieran, 27:45)
• Scientific Advances and Ongoing Uncertainties:
  Research confirmed that blast waves could damage the brain, but diagnosis, proximity guidelines, and distinguishing TBI from PTSD remained difficult.
  • "Once you know that...then the question becomes, okay, how close does a soldier have to be to the blast...that depends on a number of factors..." (Dr. Kieran, 29:42)
• Overlap with Civilian Medicine:
  The military drew heavily on advances in NFL and sports medicine concussion research.
  • "One of the researchers I talked to said there's. There's no such thing as military medicine. We don't have different medicine..." (Dr. Kieran, 34:13)

8. Addressing Rising Suicide Rates Among Active Duty and Veterans

• Surprising Patterns:
  Contrary to expectations, deployment and combat experience did not directly correlate with suicides; life stresses (e.g., relationship breakdowns, legal or financial trouble) were often more relevant triggers.
  • "There was just no correlation between any combat or deployment experience and any indication that the person would. Would die by suicide." (Dr. Kieran, 38:11)
• Loss of Garrison Leadership:
  Intensive deployment schedules eroded the traditional practice of officers keeping close tabs on soldiers’ well-being in peacetime.
• Leadership as Suicide Prevention:
  Renewed calls for “garrison leadership” emphasized the need for leaders to notice and intervene when soldiers struggled.

9. The VA’s Evolving Response to Veteran Suicides

• Surveillance and Outreach Initiatives:
  The VA began analyzing mental health trends monthly across all its regions, launching multifaceted responses.
  • "The VA worked really creatively to do first surveillance on veterans and to, to really understand every month how many veterans were coming in for mental health care..." (Dr. Kieran, 43:21)
• Critical Interventions:
  • Launch of the Veterans Suicide Hotline
  • Suicide-prevention hotline numbers on prescription bottles
  • Distribution of gun locks via partnership with sports groups
• Philosophy:
  The VA’s key aim was to “limit access to lethal means” and position itself as a welcoming source of care for modern veterans.

Notable Quotes

• "I didn't set out to write the book I eventually wrote, I think is an important part of the story." – Dr. Kieran, 02:14
• "What the army found is if we stationed...a captain who's an army psychologist...in that unit every day...more people were willing to talk to that person, even informally, about what they were experiencing." – Dr. Kieran, 21:12
• "This is a civilian problem and a military problem, but certainly escalated in the time period that I write about for the military." – Dr. Kieran, 35:08
• "The research shows that the person who is having suicidal ideations, there's a four or five minute window between when a person thinks about dying, taking their life and when they might make an attempt..." – Dr. Kieran, 44:13

Timestamps for Key Segments

• Introduction & Background: 01:07–05:38
• Pre-9/11 Doctrine: 06:00–09:50
• Mental Health Assessment Teams (MHATs): 10:11–13:10
• Mental Health and Antiwar Politics: 13:21–15:54
• Breaking the Stigma & Accessing Care: 16:09–23:01
• Challenges for Military Families: 23:12–27:10
• Evolution in Understanding TBI: 27:22–35:39
• Addressing Active Duty Suicide: 35:48–42:32
• VA Efforts on Veteran Suicide: 42:45–47:18

Memorable Moments

• The practical shift from seeing PTSD as a “veterans’ issue” to a present-tense problem for active soldiers (07:00).
• Dr. Kieran’s explanation of “battle mind” and how skills for survival in war can become maladaptive at home (17:45).
• The adoption of civilian concussion protocols in military medicine, showing crossover between sports and combat trauma (34:13).
• The army's vulnerability regarding suicide among those presumed to be the healthiest Americans (38:37).
• VA's tactically simple yet impactful strategies (e.g., suicide hotline on pill bottles and gun locks for veterans) (45:26).

Conclusion

Dr. David Kieran’s episode offers a comprehensive and nuanced exploration of the U.S. military’s struggle to understand and address signature wounds of the Iraq and Afghanistan wars—mental health crises, traumatic brain injuries, and suicides among soldiers and veterans. He highlights both the strides made and systemic shortcomings, providing a crucial historical perspective on the intersection of war, policy, stigma, and care.

For listeners and readers interested in the entwined history of war, medicine, and American society, Signature Wounds is highly recommended.